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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 802542-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the classroom without a staff person’s (SP) knowledge or supervision and was found standing by the facility’s entry door. Date of Incident(s): February 8, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 4, 2022; from documentation at the facility; and through three interviews conducted with facility staff persons. Attempts to contact the AV’s family members by telephone were unsuccessful. The facility was located in the basement of a church. The facility’s two preschool classrooms were separated by a bathroom. The bathroom had two doors, one door led to the young preschool classroom and the other door led to a hallway. The older preschool classroom accessed the bathroom through the door in the hallway. The entry doors to the facility/church were down a long hallway and up approximately ten steps to the entry way. The entry way had two glass doors that opened to the outside with a push bar. The doors were locked and accessed by a security code that was only provided to staff persons and parents of children at the facility. The entry door was monitored by cameras visible in the director’s office, which was located in the long hallway approximately half way between the bathroom door and the stairs leading the entry way. The AV’s enrollment file showed that the AV was thirty-two months old at the time of the incident and enrolled in the facility’s young preschool classroom. Facility documentation and interviews with a facility management person (P1), a facility staff person (P2), and the SP provided the following information: · P1 stated that on February 8, 2022, at approximately 3:15 p.m., s/he had just returned from picking school-age children up from school when a community person who was the parent of another child at the facility told P1 that the AV was inside the building, standing alone by the entry door of the facility. P1 went to the entry way and found the AV standing by the entry doors.
· P1 walked the AV back to his/her classroom and noticed that the classroom door to the hallway was closed but that the bathroom door to the hallway was open. When P1 talked to the SP about the incident, the SP told P1 that the AV had used the bathroom while the SP was cleaning up snack and supervising children in the bathroom and in the classroom. The SP did not notice the AV leave the bathroom through the door to the hallway. · The SP stated that s/he was working in the young preschool classroom with ten children. The AV went to the bathroom to wash his/her hands after snack and was in the bathroom with a few children from the older preschool classroom. While the AV was in the bathroom, two young preschool children started to argue so the SP’s attention was drawn to them as s/he went to intervene. After the SP finished settling the argument between the two children, the SP noticed that the AV did not come back into the classroom after the AV finished washing his/her hands. A few seconds later, P1 returned the AV to the classroom. The SP thought that the AV was without the SP’s supervision for approximately seven minutes. · P1 and the SP each stated that the AV would not be able to open the entry doors without assistance from an adult and that all of the doors are locked from the outside so a church member or community person would not be able to enter without permission. According to P1, members of the church and community were typically not at the church during the day when the children were present. When there was an event at the church, the public used other doors that were not close to the facility’s classrooms. · P2 worked with the older preschool classroom. P2 stated that s/he “typically” stood in the hallway when the children in his/her classroom used the bathroom. On the day of the incident, P2’s classroom was not using the bathroom at the same time as the AV. · According to P1, the SP and P2 were trained to supervise the children at all times which included while they were in the bathroom. · The facility’s Child Care Center Risk Reduction Plan stated that staff persons were to maintain sight supervision while children were toileting and that the staff persons were to “straddle” the classroom and bathroom doorway to maintain supervision of both rooms. · The facility’s personnel files showed that the SP was trained on the facility’s Child Care Center Risk Reduction Plan on November 23, 2020, and on the Reporting of Maltreatment of Minors Act on November 19, 2020. P1 and P2 were each trained on the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A, state that “supervision” means a program staff person is within sight and hearing of a child at all times so that the program staff person can intervene to protect the health and safety of the child; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: On February 8, 2022, the AV used the facility’s shared bathroom and left the bathroom through the open door leading to the hallway. The AV walked upstairs to the entry way doors without the SP’s knowledge or supervision and was away from the classroom for approximately seven minutes, which was a violation of Minnesota Statutes 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A. Although P1 and the SP each stated that the AV would not be able to open the entry door and that the entry doors are secured, the AV was without an adult’s supervision for approximately seven minutes and staff persons were not aware until they were notified by a community person. Given that it was unlikely that the AV would be able to exercise self-preservation skills in the event of an emergency and that the AV had exposure to dangers including community persons, there was a preponderance of the evidence that there was a failure to supply the AV with care necessary and a failure to protect the AV from conditions that seriously endangered the AV’s physical or mental health. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the supervision of the AV at the time of the incident. The SP was trained on the facility’s Child Care Center Risk Reduction Plan and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single event and it was not serious because the AV did not require medical care. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility conducted an internal review and determined that their policies and procedures are adequate but not followed at the time of the incident. The SP was retrained on the supervision requirements. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On July 29, 2022, the facility was issued a Correction Order for the violations outlined in this report. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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